OPINION

Why distinguishing a moral injury from PTSD is important

By THOMAS GIBBONS-NEFF | Special to the Washington Post | Published: March 9, 2015

Even on the short overnight ops, sometimes we talked about things we knew we'd carry home. On a cold night in March 2010, Jeff brought up the kid he'd shot a month earlier, when the battle for the Afghan city of Marjah was hot and there was no shortage of 15-year-olds picking up Kalashnikovs off the ground. Jeff had killed one of them with four shots from a heavy-caliber semi-auto that made a soft thud when the bolt released. The kid had a rifle, and even kids with rifles can kill Marines, Jeff had figured.

A few weeks later, we were on the side of the road watching for Taliban fighters digging bombs into the ground, and Jeff was telling me about it. He described the way the kid fell and how he wasn't sure he'd done the right thing.

That was five years ago. Jeff doesn't bring up that story anymore. I know he thinks about it, though, because a couple of years back he put a Remington 700 short action in his mouth and didn't pull the trigger. Rather than remaining in the flooded poppy fields of Afghanistan, the story of the kid Jeff shot stuck with him. It grew and matured just as Jeff had, until one day Jeff sat on his bed with a loaded rifle across his lap, staring at a part of his life he could no longer understand.

"I'm not crazy," he told me, and I knew he wasn't. Ten years ago we would have just called it post-traumatic stress disorder. Sixty years ago, it would have been combat fatigue. And in the shell-raked trenches of the Western Front, it would have been shell shock. But Jeff's dead kid was none of those things. Jeff's weight was something else — a moral injury.

Moral injury is a nebulous term that few use seriously because it doesn't read well on Veterans Affairs claims. It's a new term but not a new concept. Moral injury is as timeless as war — going back to when Ajax thrust himself upon his sword on the shores of Troy. Unlike post-traumatic stress, which is a result of a fear-conditioned response, moral injury is a feeling of existential disorientation that manifests as intense guilt.

David Wood, a Huffington Post reporter, describes moral injury as "the pain that results from damage to a person's moral foundation." In her forthcoming book "Afterwar: Healing the Moral Wounds of Our Soldiers," Georgetown University's Nancy Sherman thinks of moral injuries as a painful "transgression" or as an erosion of "a sense of goodness and humanity." Moral injuries, she says, have to do with failing to hold yourself or others to account. For some, it's realizing that what you choose to do or not do in combat doesn't align with the person your parents raised. The person who volunteers at rescue shelters and takes his grandmother out to lunch on her birthday doesn't seem like the same person who once reveled in the shock waves of 500-pound bombs.

Moral injury is discussed in academia but is rarely talked about — and is often misunderstood — among those who suffer from it. It isn't really a part of the "returning veteran" lexicon; instead, veterans use PTSD as a convenient catchall. Yet there is a danger in conflating post-traumatic stress and moral injury. While in many cases they can overlap, differentiating the two allows the returning veteran to understand not only the trauma he or she experienced but also the damage left by the decisions made in war.

Moral injury makes its mark by creating a flawed sense of who you were when you were in harm's way. This is the second self. Deployed veterans, morally injured or not, have this second self formed in war — one who can tell incoming from outgoing artillery and whose first reaction to an arterial bleed is to kneel into their best friend's pressure point.

Back in civilian life, that second self must merge with the present self — the person who wanders the aisles at Safeway and wakes up to the soft bleat of an iPhone alarm. Those months, or even years, of transition are wrought with moments that confuse the two selves. Strange moments in movie theaters when folded American flags make your breath come short and hot; or on the Fourth of July, when the muted pop of bottle rockets induces a nostalgia you can't explain. Even the smell of burning trash reminds you of a place you'd secretly rather be.

Time passes, and most of us find a way to remember the old self. The self that was younger and faster and damn good-looking under that half-cocked helmet. Those memories are put in boxes or hard-drive folders labeled "Spring Break Afghanistan." Your war stories become well-rehearsed scripts, and even your traumas, those hellacious days when you bore witness to the young and the dead, are scrubbed and polished and placed in a mental vault that you know how to open — or keep shut.

But moral injury makes it hard to transition from memory to the present; it confuses the old self and the new. If the injury is severe enough, it can be almost impossible to see yourself in the present. Instead, you see the person who was capable of making the wrong decision when, years later, you know you could have made a different one.

My friend Jeff remembers his old self by wearing around his neck the bullet he almost used to end his life. It is a reminder, he says, of the moment he could no longer bear the pain of what he had done that day in 2010 — and what he had to do to move on. After he didn't pull that trigger, he decided to live — and to share his experience with me and other Marines he had served with. In many ways, Jeff transfused his moral injury into the bullet. He turned the emotional damage into a physical object — a reminder of when he strayed from his values — that he could balance in his palm and run his fingers over.

As a nation, we have spent the past 14 years at war. Men and women have returned. Some have returned broken. It is our job, as a country, to understand what broken means. We have reached the point where PTSD is bandied about as a diagnosis, a fallback and a lens through which to consider, and sometimes wrongly label, those troubled by our conflicts. But what happens when the drugs we prescribe or the approaches we take are misguided? What happens when we treat for the wrong injury?

Recognizing moral injury isn't so much about how the country understands its veterans; rather it is about how veterans understand themselves. Moral injury usually stems from a precise moment in a service member's experience and is not an abstract issue, nor another name for PTSD. "Moral injury is so personal in so many ways," says Molly Boehm, a former case manager for recovering Marines and soldiers at Walter Reed National Military Medical Center. "It's about reconciling that event" that sticks with you, she says. "And it's also about reconnecting with a moral community, feeling connected to your fellow man."

While treatment for moral injury — such as group therapy — sometimes overlaps with treatment for PTSD, it usually differs in the sense that the morally injured need to have an ethical dialogue as well.

To understand moral injury and address its effects, we need to recognize that it exists. If we don't, if we continue to categorize moral injury under the same umbrella we have for centuries, those who have borne our wars will have to carry their own wounded. Those faceless few with draped arms over slouched shoulders will still be trudging across the terrain of battles fought long ago.

Thomas Gibbons-Neff, a senior at Georgetown University, was a 2014 Washington Post summer intern. He served as a rifleman in the 1st Battalion, 6th Marines in Afghanistan in 2008 and 2010.